Definition of Polypharmacy in Heart Failure: A Scoping Review of the Literature.

Patients with heart failure (HF) have a high prevalence of polypharmacy, which can lead to drug interactions, cognitive impairment, and medication non-compliance. However, the definition of polypharmacy in these patients is still inconsistent. The aim of this scoping review was to find the most common definition of polypharmacy in HF patients. We conducted a scoping review searching Medline, Embase, CINAHL, and Cochrane using terms including polypharmacy, HF and deprescribing, which resulted in 7,949 articles. Articles without a definition of polypharmacy in HF patients and articles which included patients < 18 years of age were excluded; only 59 articles were included. Of the 59 articles, 49% (n = 29) were retrospective, 20% (n = 12) were prospective, 10% (n = 6) were cross-sectional, and 27% (n = 16) were review articles. Twenty percent (n = 12) of the articles focused on HF with reduced ejection fraction, 10% (n = 6) focused on HF with preserved ejection fraction and 69% (n = 41) articles either focused on both diagnoses or did not clarify the specific type of HF. The most common cutoff for polypharmacy in HF was five medications (59%, n = 35). There was no consensus regarding the inclusion or exclusion of over-the-counter medications, supplements, or vitamins. Some newer studies used a cutoff of 10 medications (14%, n = 8), and this may be a more practical and meaningful definition for HF patients.

Dopamine projections to the basolateral amygdala drive the encoding of identity-specific reward memories.

To make adaptive decisions, we build an internal model of the associative relationships in an environment and use it to make predictions and inferences about specific available outcomes. Detailed, identity-specific cue-reward memories are a core feature of such cognitive maps. Here we used fiber photometry, cell-type and pathway-specific optogenetic manipulation, Pavlovian cue-reward conditioning and decision-making tests in male and female rats, to reveal that ventral tegmental area dopamine (VTADA) projections to the basolateral amygdala (BLA) drive the encoding of identity-specific cue-reward memories. Dopamine is released in the BLA during cue-reward pairing; VTADA→BLA activity is necessary and sufficient to link the identifying features of a reward to a predictive cue but does not assign general incentive properties to the cue or mediate reinforcement. These data reveal a dopaminergic pathway for the learning that supports adaptive decision-making and help explain how VTADA neurons achieve their emerging multifaceted role in learning.

A rare case of type 2 Kounis syndrome secondary to iodinated contrast.

Immune-mediated acute coronary syndrome, also known as Kounis syndrome (KS), is an underrecognized and challenging diagnosis. In this case report, we present a case of cardiac arrest secondary to iodinated contrast allergy requiring emergent cardiac catheterization and hemodynamic support secondary to type 2 KS. KS necessitates a high index of clinical suspicion by the treating physician in order to address both the hypersensitivity reaction and its cardiac implications. Learning objectives: Kounis syndrome (KS) is a clinically distinct entity from anaphylaxis; managing KS in the same way as anaphylaxis can worsen cardiac demand and ischemia. In addition, KS may present as coronary vasospasm or plaque rupture; regardless, percutaneous coronary intervention (PCI) should be performed as worse outcomes have been described in cases where PCI is not performed or delayed.

Role of Psychologists in Pediatric Congenital Heart Disease.

Congenital heart disease (CHD) is stressful to both pediatric patients and their caregivers. Maternal anxiety during pregnancy is associated with adverse perinatal outcomes. After birth, a prolonged hospital stay can be taxing on the infant and caregiver leading to long-term adverse effects. During adolescence, CHD continues to serve as a stressor for the child not only due to medical care but also due to social limitations and bullying. Many patients also struggle during the transition from adolescence to adult care. Psychologists may aid both the parents and child at all stages from pregnancy to the child's transition to adulthood.

A Rare Complication of Herpes Zoster: Segmental Zoster Paresis.

Segmental zoster paresis (SZP) is a rare complication of herpes zoster (HZ) that results in focal weakness of the extremity in the myotome that corresponds to dermatomal involvement.We present a case of an 80-year-old female with a resolving HZ rash on her left leg and buttocks that presented with left leg weakness for two weeks. The patient's rash preceded the left leg weakness by two weeks. The exam revealed erythematous macular and crusting lesions in the left L3/L4 distribution. The left thigh was flaccid with 1/5 knee extension strength with an absent patellar reflex. Lumbar spine magnetic resonance imaging (MRI) revealed enhancement of the left L4 roots, suggestive of inflammation or neuropathy. The patient was discharged on gabapentin, amitriptyline, and a two-week prednisone taper. In this case study, we present SZP, a rare complication that occurs in approximately 3% of HZ patients. The majority of SZP cases occur on the face or upper extremity, whereas our patient had SZP of the lower extremity. This case emphasizes the importance of maintaining a comprehensive differential diagnosis and highlights that SZP should be considered in patients who present with acute weakness in an extremity.

Utilizing Percutaneous Cholecystostomy Tube as a Temporary Minimally Invasive Approach for Acute Cholecystitis during Third Trimester of a High-Risk Pregnancy.

Laparoscopic cholecystectomy (LC) is the treatment modality of choice for symptomatic cholelithiasis and cholecystitis during pregnancy and is associated with shorter length of stay, shorter operative times, and fewer complications compared to open cholecystectomy. However, in high-risk pregnant patients, LC can be challenging. Percutaneous cholecystostomy tube (PCT) offers a temporary management option during the peripartum period until interval LC is performed. We present a case of a high-risk pregnancy involving a 41-year-old woman at the 34th week of gestation with a dichorionic-diamniotic-twin gestation with signs and symptoms of acute cholecystitis. Given the patient's high-risk status, a less intensive intervention, PCT, was performed for gallbladder decompression. An interval LC was performed on postpartum day 4 after caesarean section. Current surgical guidelines suggest that laparoscopy can be safely used to treat biliary disease during pregnancy in all trimesters. Although rarely used as a first-line intervention for gallbladder disease, PCT is an important minimally invasive procedure for treatment of cholecystitis in patients who are poor surgical candidates. Our case is unique due to the twin gestation, advanced maternal age, and gestational age.

Opioid-Associated Amnestic Syndrome.

Opioid-associated amnestic syndrome (OAS) is a relatively new condition that is associated with opioid abuse and has increased in prevalence since the notable rise in opioid-related deaths and opioid-related hospitalizations of the opioid crisis. Patients often present with acute anterograde amnesia and current opioid abuse, most commonly fentanyl. OAS is frequently diagnosed when other potentially infectious or metabolic conditions such as encephalitis and seizures are ruled out, as these conditions can also present similarly to OAS. This case highlights the signs, symptoms, and hallmark characteristics of OAS, including bilateral hippocampal edema and anterograde amnesia.

Suspected Post-ictal Psychosis in Temporal Lobe Epilepsy Secondary to Human Herpesvirus 6 Encephalitis.

Human herpesvirus 6 (HHV-6) may lead to temporal lobe epilepsy (TLE). Psychotic syndrome frequency in the setting of TLE is 7% to 11%. We report a case of post-ictal psychosis (PIP) secondary to TLE in the setting of HHV-6 encephalitis. A 58-year-old male presented with a two-day history of severe confusion, personality changes, and new-onset psychosis. Lumbar puncture was positive for HHV-6. Electroencephalogram (EEG) revealed left temporal sharp waves during drowsiness and sleep, suggestive of focal epileptiform discharges without clinical seizures. Valproate and olanzapine were employed for epilepsy and agitation. Psychosis and confusion resolved with subsequent discharge. Out of the other diagnoses, PIP in the setting of TLE secondary to HHV-6 given the clinical response to acyclovir. While HHV-6 encephalitis may cause TLE, this patient did not have a history of seizures and EEG did not capture active seizures. It is unclear if the sharp waves were incidental or indicative of TLE. Additionally, PIP is seen more commonly with left-sided EEG changes. Low-dose olanzapine was efficacious in resolving symptoms, which is typical in PIP. Both HHV-6 encephalitis and TLE have the potential to cause memory impairments and personality changes, which were seen in this patient. Patients with both TLE and PIP are less likely to exhibit focal ictal discharges than those with only TLE, which may explain the absence of active seizure activity on EEG.

Left Ventricular Thrombus Formation in a Young Female With a Severely Reduced Left Ventricular Ejection Fraction and a Recent Non-ST Segment Elevation-Acute Coronary Syndrome.

A 30-year-old female with a past medical history of heart failure with reduced ejection fraction (HFrEF of 20%), non-ST segment elevation-acute coronary syndrome (NSTE-ACS), and polysubstance abuse (heavy alcohol and methamphetamine use) was admitted for a heart failure exacerbation. Electrocardiogram and troponin levels were negative. Pro brain natriuretic peptide was elevated at 4,152 pg/mL. The patient was restarted on guideline-directed HFrEF therapy and continued to improve. Two days after presentation, the patient was transferred to the intensive care unit for severe alcohol withdrawal, requiring intravenous phenobarbital and dexmedetomidine. After her withdrawal symptoms resolved, she complained of right-sided weakness and stroke-like symptoms. Brain magnetic resonance imaging (MRI) and computed tomography (CT) were both negative. Echocardiography revealed an ejection fraction of 20% and a severely dilated left ventricle with a 2.1 x 1.2 cm apical density, suggestive of a thrombus, and the patient was started on apixaban. Echocardiography two months prior to this admission revealed an ejection fraction of 20%, but there was no evidence of a thrombus. Our patient had three major risk factors for left ventricular thrombus (LVT) formation: severely reduced left ventricular ejection fraction (LVEF), dilated cardiomyopathy (DCM), and a recent NSTE-ACS two months prior. This case highlights the importance of anticoagulation in patients at high risk for LVT formation and emphasizes the DCM may be seen in younger patients with heavy alcohol and amphetamine use.

Plummer-Vinson Syndrome in an African-American Woman.

Plummer-Vinson syndrome (PVS) presents with the classic triad of iron-deficiency anemia, dysphagia, and esophageal webs. The mainstay treatment of PVS is iron supplementation and the dysphagia usually responds to iron supplementation before the hematologic abnormalities are corrected. This syndrome classically affects middle-aged Caucasian women and very few cases have been reported in African Americans. We present a rare case of PVS in an African-American woman. A 63-year-old woman presented with shortness of breath, dysphagia, and lightheadedness for several weeks. Chest X-ray was negative for any acute abnormalities. Initial hemoglobin was 7.0 g/dL, which improved to 7.5 g/dL after 1 unit of packed red blood cells. She had a mean corpuscular volume of 62 fL, a ferritin level of 6 ng/mL, and an iron level of 12 µg/dL. Fecal occult blood test was negative and barium swallow revealed a proximal esophageal web. Her dysphagia did not significantly improve despite intravenous iron supplementation and esophageal web dilation. Video-fluoroscopic swallow study revealed esophageal and pharyngeal phase dysphagia with food entrapment. She was discharged with plans to follow up with a primary care physician and repeat esophagogastroduodenoscopy in 1 year. This case report highlights a rare case of PVS in an African-American woman and emphasizes the importance of maintaining a comprehensive and broad differential diagnosis.

Spontaneous Bile Leak in a Patient Without Recent Abdominal Surgery or Trauma.

Bile leaks are a rare occurrence most often seen as a complication of cholecystectomy. Other less common etiologies include endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), liver surgery, percutaneous drainage of liver abscesses, living donor hepatectomy, and non-iatrogenic abdominal trauma. In this case study, we present a 67-year-old female with morbid obesity who presented with abdominal pain and was diagnosed with a spontaneous bile leak. She had no history of recent surgery or abdominal trauma. CT revealed that the patient's gallbladder was located in the right lower quadrant, most likely due to mass effect from a large ventral hernia, and possible fluid collection extending from the gallbladder along the surface of the anterior inferior right hepatic lobe. Hepatobiliary iminodiacetic acid (HIDA) was performed due to a concern for cholecystitis. HIDA demonstrated a bile leak in the right upper abdomen of unknown etiology. Initially, there was a concern for gallbladder obstruction. Gastroenterology recommended magnetic resonance cholangiopancreatography (MRCP), however, MRCP was not possible due to the patient's body habitus. The patient had normal liver function tests, was tolerating oral intake, and her abdominal pain resolved, therefore, we became less suspicious of gallbladder obstruction. This case suggests that bile leak should be included in the differential diagnosis for abdominal pain even in patients who have not had recent abdominal surgery or procedures. This case also highlights the unique anatomical finding of a right lower quadrant gallbladder secondary to mass effect from a large ventral hernia.

The Role of Psychiatric, Analgesic, and Antiepileptic Medications in Chronic Pruritus.

Chronic pruritus is a complex yet prevalent concern without a gold standard treatment. The mainstay therapy for chronic pruritus includes topical ointments such as corticosteroids, capsaicin, local anesthetics, antihistamines, and immunomodulators. There are many different subtypes of chronic pruritus, and each unique subtype may benefit from specialized treatments. This review article sheds light on the role of psychiatric, analgesic, and antiepileptic medications in chronic pruritus. We believe that further large-scale studies are needed to determine the true effectiveness of these medications in treating chronic pruritus.

Leptomeningeal Carcinomatosis Secondary to a Gastrointestinal Stromal Tumor.

A 66-year-old male presented to the emergency department (ED) with altered mental status and concern for stroke. Seven months prior to presentation, the patient was diagnosed with a benign gastrointestinal stromal tumor (GIST), for which he did not receive further workup. Initially, there was a concern for a stroke, however, CT of the brain, CT angiography of the head and neck, and MRI of the brain were negative for any acute abnormalities. Lumbar puncture (LP) revealed a low glucose level with increased protein and white blood cells in the cerebrospinal fluid (CSF). The patient did not display the typical signs and symptoms of meningitis, however, inpatient antibiotic treatment was initiated. The patient continued to deteriorate and repeat LP with cytology was ordered, which revealed malignant cells that were similar to the biopsy of the GIST; our patient was diagnosed with leptomeningeal carcinomatosis (LMC) secondary to the GIST. This case report presents a rare complication of a solid GIST and highlights the need for a high clinical index of suspicion for LMC, including those previously deemed to be benign.

The other side of atopic dermatitis: An evaluation of psychosocial comorbidities.

Atopic dermatitis is a chronic skin disease that commonly affects patients. In addition to its effects on the skin, it has also been associated with other physical, psychosocial, and economic burdens along with numerous debilitating comorbidities. More recently, research has focused on the psychosocial and mental health aspect of atopic dermatitis, which has remained controversial. We reviewed the current literature and have discussed the association of atopic dermatitis with suicide, attention-deficit/hyperactivity disorder, and schizophrenia.

Initial Presentation of Renal Cell Carcinoma as Heart Failure Secondary to Tumor-Thrombus Extension to the Right Atrium.

Renal cell carcinoma (RCC) can invade locally through the renal vein and into the inferior vena cava (IVC) with tumor-thrombus formation reported in 5%-15% of patients. From the IVC, RCC can grow intravascularly and extend into the right atrium. We present a rare case with two uncommon findings: tumor-thrombus extension leading to a right atrial mass and initial presentation of RCC as heart failure. A 69-year-old woman presented with signs and symptoms of heart failure. Electrocardiogram was normal and the initial troponin level was mildly elevated to 0.09 ng/mL. Echocardiography revealed a dilated right atrium with a 6.9 cm x 3.8 cm echogenic mass consistent with a tumor impinging on the tricuspid valve leading to a functional stenosis. Computed tomography (CT) of the abdomen revealed a large right-sided renal mass with enlargement of the renal vein suggestive of tumor thrombus. Although the initial presentation of RCC with cardiac symptoms is surprising, this case highlights the importance of maintaining a comprehensive differential diagnosis. It also signifies the need for further imaging as not all atrial masses are cardiac tumors. Many other primary tumors - kidney, liver, lung, and thyroid - can directly invade or metastasize into the atrium by way of the vena cava.

Acne Vulgaris: The Majority of Patients Do Not Achieve Success According to FDA Guidance.

BACKGROUND: The Food and Drug Administration (FDA) recommends grading Acne vulgaris via an Investigator’s Global Assessment (IGA) scale and assessing treatment as either success or failure, with success defined as clear (grade 0) or almost clear (grade 1) with at least a two-grade improvement in acne severity from baseline. OBJECTIVE: To determine the likelihood of achieving real world treatment success in patients with acne according to FDA guidance. METHODS: We calculated estimated appropriates to obtain the IGA 0/1 (clear or almost clear rate) for many of the oral and topical medications. We also used the National Ambulatory Medical Care Survey (NAMCS) data to determine the number of medications prescribed for outpatient visits when isotretinoin was prescribed or when isotretinoin was not prescribed and the one and only diagnosis was acne. RESULTS: Isotretinoin had the highest IGA 0/1 at 87%. None of the other medications had an IGA 0/1 > 40%. Of all outpatient acne visits, only 6% receive isotretinoin. When excluding isotretinoin visits, 71% of patients received ≤ 2 medications. LIMITATIONS: The majority of the acne medication studies lasted 12 weeks, however, it can take 6 months or longer to get the maximum effect. None of the studies combined topical and oral medications. CONCLUSIONS: The majority of acne patients are not likely to achieve success according to FDA guidance. We propose that the FDA guidance may be too rigorous. An alternative hypothesis is that most acne patients are undertreated. J Drugs Dermatol. 2021;20(6):648-651. doi:10.36849/JDD.5727.

Funding and Billing for Integrated Behavioral Health Care.

Integrated behavioral health care (IBHC) improves patient outcomes, decreases cost, and increases patient satisfaction. It has become increasingly evident that IBHC must be incorporated into the US health care system. Although most health care providers agree that IBHC is beneficial, there is great debate regarding financial sustainability. Some studies have shown that incorporating BHCs into primary care clinics allows providers to see more patients, thus generating more revenue indirectly. In this article, the authors discuss funding and billing for IBHC. The authors truly believe that once properly implemented, IBHC will lower costs and improve patient care in the long run.

Limited processivity of single motors improves overall transport flux of self-assembled motor-cargo complexes.

Single kinesin molecular motors can processively move along a microtubule (MT) a few micrometers on average before dissociating. However, cellular length scales over which transport occurs are several hundred microns and more. Why seemingly unreliable motors are used to transport cellular cargo remains poorly understood. We propose a theory for how low processivity, the average length of a single bout of directed motion, can enhance cellular transport when motors and cargos must first diffusively self-assemble into complexes. We employ stochastic modeling to determine the effect of processivity on overall cargo transport flux. We show that, under a wide range of physiologically relevant conditions, possessing "infinite" processivity does not maximize flux along MTs. Rather, we find that lowering processivity, i.e., weaker binding of motors to MTs, can improve transport flux. These results shed light on the relationship between processivity and transport efficiency and offer a theory for the physiological benefits of low motor processivity.

Successful Intubation of a Difficult Airway Using a Yankauer Suction Catheter.

BACKGROUND: Endotracheal intubation (ETI) is used to effectively manage a patient's airway. Failure of ETI may lead to ineffective ventilation or oxygenation, potentially causing organ damage and eventually death. Approximately 8% of ETIs are difficult and 1% are unsuccessful. Tools and techniques to successfully obtain airway access are essential. CASE REPORT: A patient with chronic obstructive pulmonary disease presented to the emergency department in acute respiratory distress. Noninvasive positive pressure ventilation was unsuccessful in improving the patient's tidal volume and work of breathing. The patient was unable to be intubated by conventional techniques because of a mass obstructing the view of her vocal cords. A cricothyrotomy was considered, but not initially performed because of her distorted anatomy. After multiple intubation attempts from several different physicians, the patient was successfully intubated with the aid of a suction Yankauer, which was used to move the mass peripherally and further served as a conduit through which a bougie was passed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The risk for complications rises with each intubation attempt. While there are a variety of tools and aids that can be used to assist in difficult intubations, rapid airway access is essential, and common tools do not always work. We hope that knowledge of this novel, yet simple and effective technique will help physicians successfully intubate patients with distorted oropharyngeal anatomy who cannot be intubated using conventional methods.